Provider Demographics
NPI:1477740546
Name:LAURIE M. WOLL, D.O., DERMATOLOGY, A MEDICAL CORP
Entity Type:Organization
Organization Name:LAURIE M. WOLL, D.O., DERMATOLOGY, A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-621-5005
Mailing Address - Street 1:9301 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2420
Mailing Address - Country:US
Mailing Address - Phone:909-621-5005
Mailing Address - Fax:909-621-4900
Practice Address - Street 1:9301 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2420
Practice Address - Country:US
Practice Address - Phone:909-621-5005
Practice Address - Fax:909-621-4900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ88928ZMedicare PIN
CAW10544Medicare PIN